Operational Biosurveillance

"The Matrix Has You": H7N9 Signature Tracking

Reminiscent of The Matrix, the astute analyst monitors the signature pattern in near-real time as information is reported on H7N9:  

This is the actual "rhythm strip" of H7N9, read from top to bottom, where the bottom includes the more recent reports.  Each dot is an indicator of specific interest to the analyst.

The state of the art in operational biosurveillance is 1) automation, 2) overlays of artificial intelligence-based assessments, and 3) signature pattern forecasting.  This is how the work is done when watching the global output of infectious disease event reporting.

 

 

Proof of Performance: Daily Forecasts of Routine Pediatric Diagnoses

Here we compare daily disease forecasts issued 60 days in advance during 2012.  These forecasts were based on four years of prior data (2008-2011).

We've been reaching daily forecast accuracies that are generally in the 85-90% range, meaning 85-90% of the time our daily forecasts for a given disease are falling with +1 / -1 standard deviation of the forecasted mean for the given day.  Forecast lines related to RSV and hMPV were off in 2012 due to the appearance of the worst winter respiratory season documented in the last five years of the hospital.  In this case, the forecast facilitated rapid recognition of unusual disease patterns.

Below are example proofs of forecast performance.  We expect these statistics to improve over time with access to more data.  What is being forecasted here is the Infectious Disease Medical Infrastructure Strain Index (IDMIS), which is a function of case count, by medical disposition (outpatient, emergency dept, inpatient, ICU).  The IDMIS is an operational "bottom line" that highlights expected stress placed on a local medical infrastructure.  Higher IDMIS values indicate greater strain.

For each of the example diseases below, the top graph reflects the daily forecasted mean, with +1 / -1 standard deviation values.  The majority of the diseases are associated with zero -1 standard deviation values.  In other words, we could either see X cases or zero cases for any given day.  The bottom graph reflects what was actually observed in 2012.

 

Gastroenteritis (82% daily forecast accuracy)

 

Strep Pharyngitis (98% daily forecast accuracy)

 

Viral Infection (100% daily forecast accuracy)

 

 

Acute Conjunctivitis (84% daily forecast accuracy)

 

 

Acute Otitis Media (89% daily forecast accuracy)

 

Acute Sinusitis (89% daily forecast accuracy)

 

Acute Pharyngitis (88% daily forecast accuracy)

 

Croup (57% daily forecast accuracy- due to unusually severe RSV season in 2012)

 

Acute Upper Respiratory Infection (94% daily forecast accuracy)

 

RSV Bronchiolitis (65% daily forecast accuracy due to non-routine, unusually severe season in 2012)

 

RSV-/Influenza-Negative Bronchiolitis (81% daily forecast accuracy due to non-routine, unusually severe season in 2012)

 

 

Pneumonia (86% daily forecast accuracy)

 

Reactive Airway Disease Exacerbation (86% daily forecast accuracy)

 

Cellulitis (86% daily forecast accuracy)

 

Dialogue Between a Meteorologist and an Operational Biosurveillance Analyst

Dialogue Between a Meteorologist [M] and an Operational Biosurveillance Analyst [OBA]:

 

[M] A forecast is a prediction of an event before it begins.  If the event has begun (e.g. a hurricane) at a given location, updates are called "nowcasts." For example, the initial wind speed forecast for hurricane Sandy at Battery Park might have been 60 mph. If the storm has started and the forecast is raised to 70 mph, that would be a nowcast. 

 [OBA] There are many in public health who claim forecasting cannot be done.  This is simply not true for a wide variety of infectious disease conditions.  Indeed we are discovering there are a multitude of health outcomes only peripherally related to infectious disease that can be forecasted as well.  Among those who are practicing physicians, this has been long captured in the classic discourse between physician and patient.  For example, "don't smoke or you may develop lung cancer".  The meteorological notion of a "nowcast" has been done routinely now for several years at the National Infectious Disease Forecast Center as well as some of our other engagements overseas such as Haiti.  "Nowcasts" are also performed by public health, however at nowhere near the depth of coverage as we are able to provide now via direct linkages to clinical medical data (which is a major source of public health advisories).  Public health advisories are but the barest subset of what is observed on a daily basis in clinical medicine and that is relevant to the Public Interest.

[M] Climatology represents the long term averages (in meteorology, usually 30 years or more). Climatology tells us that, in NYC, January, on the whole, will be colder than July.   Persistence is the tendency of the weather of tomorrow to be like the weather of today.  A forecast is considered "skillful" if it beats both "climatology" and "persistence".  If it is sunny and 75° today and exactly the same thing occurs tomorrow, even a perfect forecast is not "skillful" because there was no change in the weather.

[OBA]  Excellent point.  However what is considered state of the art in meteorology is not so in operational biosurveillance.  Indeed, the vast majority of healthcare providers operate in reactive mode, simply addressing disease one patient at a time and deciding whether or not to treat with antibiotics.  With the exception of influenza, most physicians have no idea what their local baselines are for rhinovirus, metapneumovirus, Salmonella, etc etc etc.  In other words, a lack of comprehensive understanding of one's own local baseline.  This unfortunately extends to local antibiotic resistance patterns, where we are clearly losing several important battles with resistance in our communities.

So, current state of the art in operational biosurveillance is a few exceptions representative of "skilled" forecasts (e.g. influenza vaccine drift) and a greater majority of "unskilled" forecasts.  However what is considered "unskilled" from the strict definition of meteorology is considered utterly "skilled" by your average healthcare provider and the public because they are unaware of their baselines in the first place.

[M]  We have previously discussed the concept of adopting the Watch / Warning terminology used by meteorology in the event a forecastable major adverse health event presents itself. If I recall correctly, watches by the National Weather Service are issued at longer time periods (~ two days out) with a 30% threshold. In other words, if the forecasters believes there is a one-in-three chance of an occurrence, a Watch is issued. If, as the start of the event grows closer, a Warning is issued when the confidence reaches 70% at roughly 24 hours out. 

An issue we will have to consider as our forecasts are adopted on a wide basis is, to what extent did our forecast cause a different outcome than what would have occurred naturally? Triple-digit tornado death tolls were relatively common prior to the creation of the tornado warning program. They are exceedingly rare now (even with a large population) because of the warning system. The forecasts have changed the outcomes (fewer deaths than would exist without the warning system). 

Assume we issue an "Influenza Watch." Our watch then prompts a proactive and effective vaccination program. Our watch may have the effect of surpressing the number of cases needed to "verify" (another word would be "validate") our forecast.  In other words, if we forecast 10% of the population will contract influenza and there is a subsequent vaccination program, and the actual number is turns out to be 6% was it because we made an inaccurate forecast or was it because of the vaccination program?

[OBA]  This is a crucial point.  Anecdotally, we have observed patients flocking to our pediatric practice requesting influenza vaccination because 1) we issued advisories to them months in advance of the forecasted drift season; 2) the bulk of our patient families support influenza vaccination; and 3) the community is small enough where "everyone knows each other" and therefore share stories of children who were unvaccinated and later hospitalized with influenza.  So, the pre-event forecast (i.e. well ahead of the first confirmed influenza case in the county) began the community orientation process, followed by discussion after discussion family by family in the clinic as they asked about the forecast, followed by that single case of a hospitalized unvaccinated child to show the "proof of threat" as well as "proof of preventive action".  We then issued "nowcasts" updating the public as to what we were seeing in the hospital: that the hospitalized were almost universally unvaccinated.  We observed several of the "vaccine refusers" reconsider their position in the context of this powerful local community influence.

All of the above said, operational validation does not equate to academic validation.  And we readily acknowledge the question of validation to be a tremendous challenge when prognosticating disease. Conversely, we have often pointed out that academic studies and peer-review does not often transition into the reality of daily clinical medicine.   There is tremendous challenge here. 

Only by building years of operational experience may we have the necessary data to address this challenge.

 

 

Forecast Warning Sequence: 2012-2013 US Influenza Season

As the US national influenza season peaks out, it is important to review the importance of operational forecasting, "live" situational awareness, and proactive response in the local community setting.

Introduction

The Ascel Bio National Infectious Disease Forecast Center resides on the Western Slope of Colorado and issues monthly forecasts and "live" advisories covering approximately 100 infectious diseases.  The director of the center is a practicing pediatrician whose patients voluntarily sign up for access to the forecasts.  These forecasts are distrbuted electronically to local healthcare providers, school nurses, veterinarians, public health officials, pharmacists, EMS, and other members of the networked healthcare community.

The lay community is sharply polarized between those who vaccinate their children versus those who refuse the influenza vaccine only or the entire pediatric vaccination series (e.g., DTaP, HIB, IPV, Rota, etc).  This belief system does not fall squarely within one political bias or another such as liberal versus conservative.  However, the anti-vaccination belief system is firmly rooted in this rural community and is extremely difficult to counteract through clinical guidance.

Forecast Warning Sequence

The forecast warning sequence for the 2012-2013 influenza season has been previously described here.  This is the second time our team has successfully forecasted a vaccine drift season of influenza. 

 Forecasts were issued to the local community as such:

1. The community was pre-sensitized in the first week of September to the topic of influenza as a result of advisories issued by the Center regarding the local county agriculture fair (i.e. the concern of emerging A/H3N2 variant).
2. This was followed by the general forecast, which again emphasized concern for emerging A/H3N2 variant in late September.
3. In October, concern about a vaccine drift season of influenza was shared with patient families in the clinic, with emphasis on the need to vaccinate with the seasonal vaccine.  It was expressed the vaccine was expected to be well-matched to the drifted strains.  Limitations of vaccine efficacy overall were known to the clinician and expressed to patient families such as the vaccine is thought to prevent hospitalization, severe morbidity, and mortality.  This face to face dialog was maintained with every family that came to the clinic, regardless of chief complaint, throughout the season.
4. On October 25th, the November-December forecast was released to the community, which emphasized the same points described in bullet #3 above. 
5. On November 14th, an advisory was issued that described the first hospitalization of a combined RSV/influenza B patient. 
6. The December-January forecast was released on December 2nd, again emphasizing the need to vaccinate for influenza. 
7. Another advisory issued on December 12th with the second hospitalization of RSV/influenza B.
8. On January 7th, the January-February forecast was issued, again with emphasis on vaccination.

Results Thus Far

• All hospitalizations have been of children either incompletely or totally unvaccinated with this season's influenza.
• We have "converted" 4 families (each with between 1-3 children) who previously were staunch opponents to the influenza vaccine.
• Only 2 families (x2 children) refused influenza vaccination.  We estimate >99% compliance.
• The pediatric service has not been overwhelmed by influenza hospitalizations.  We have seen less than 5 children who presented at the outpatient level that were previously vaccinated.  None of these children had serious disease.

Preliminary Conclusions

• Development of trust with the receiver community was paramount to successful deployment of infectious disease forecasts.
• Issuance of operational forecasts coupled to updated "live" advisories drove compliance.
• Full transparency about vaccine efficacy directly relates to maintenance of trust with patient families.
• Issuance of operational forecasts coupled to updated "live" advisories that were trusted by the public ultimately resulted in mitigation of surge within a fragile pediatric healthcare infrastructure. 
• Prevention of hospitalization or transfer out of facility due to influenza is more cost-effective than lack of an aggressive vaccination education campaign facilitated by forecast and tactical warning.

 

 

 

Nested Warning Failure: Novel Coronavirus

This is a post heavily revised from an initial one (since retracted) where we expressed substantial outcry over the warning failure of Jordan.  After years of monitoring the world for infectious disease crises, even an analyst feels the need to push the chair back from the computer, run hands through hair, and give a good yell of anger.  The point of frustration is a continually demonstrated inability to protect through the action of warning, a problem that has been resident in the global public health infrastructure since at least World War II. 

 

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Here we present a case of nested warning failure involving multiple source countries associated with what is now known as “novel coronavirus” who resisted reporting of an international health event of serious potential public health impact… and allow the International Health Regulations to do what they were supposed to do: provide warning.  Here we define the word warning as:

 

something that warns or serves to warn; especially : a notice or bulletin that alerts the public to an imminent hazard

 

When originally conceived, the International Health Regulations provided a mechanism of simply expressing disease notification priorities for the international public health community.  This community, when considered on a routine operational basis, functions in parallel but separately from daily clinical medicine.  When it comes to the issuance of warning, information is withheld due to a variety of reasons:

 

• permission to distribute the information given by the source;
• concerns about instigating “panic”, with specific concern for economic disruption;
• protection of the involved public health agency’s credibility in a situation of high uncertainty; 
• concerns about disruption of diplomacy;
• security concerns related to questions of attribution or proximity to a highly charged conflict zone or area of political instability;
• lack of appropriate professional competency in the analysis of infectious disease event signatures and issuance of warning;
• lack of diagnostic confirmation;
• ineffective leadership;
• potential for embarrassment to political leadership that public health answers to, be they funders or hierarchical governmental authority (or both);
• and so on.

 

Several key events in modern times such as the emergence of HIV/AIDS, outbreaks of Ebola, translocation of West Nile virus to the western hemisphere, and so on highlighted the need to update the process of international health event reporting into a framework that offered more agility in reporting... that served the public health community and its trappings within its political sensitivities.  The time period was the late 1990s, amidst a new marketing effort that encompassed and combined the concerns of emerging pathogens, antimicrobial resistance, and bioterrorism.

 

The latter topic evoked a demand to integrate national security interest (on the part of the UN Member States) with that of public health to produce the concept of health security.  Many of the jaded old guard in public health felt this would represent simply the old "hat trick" of the late 1990s: “give me funding to ‘stop Ebola’ and I will reroute the funding to higher public health priority areas such as cholera”.  Indeed, there remains tremendous debate about prioritization of those infectious disease threats that are truly disruptive to society writ large... and that overlap with national security concerns.  Here we offer the same viewpoint in the President's recent perspective of biosurveillance, which acknowledges what those of us in the profession knew for years: that the concerns of attribution (i.e. intentional, accidental, or natural etiologies) are irrelevant from the perspective of warning and immediate response.  In other words, the trite phrase, "Mother Nature is the worst terrorist."  Of course, there were exceptions to this rule, as exemplified by the political exploitation of knowledge that the UN accidentally introduced cholera to the Haitians.  Such exploitation can interfere with emergency medical response efforts as politically motivated conflict erupts.

 

In the late 1990s, a small group of individuals filled the gap left by a lack of bureaucratic recognition of the need for more agile reporting.  This was an important pre-institutionalization period, where the International Health Regulations had not been updated, and there was a fair amount of unstructured agility in infectious disease event reporting.  This was the time period that GPHIN, ProMED, and the GOARN were born.  This was a time when it was recognized the bulk of unusual infectious disease reporting to WHO was via media reporting due to lack of indigenous public health infrastructure, lack of Member State willingness to report, among other reasons.  Since SARS, however, bureaucratization of the process has now resulted in a mechanism that certainly can not be called "agile".  

The tension has always revolved around encouraging a Member State to report versus maintaining trust by respecting their wishes whether to report.  This has been a problem for years.  Unfortunately, the events of SARS showed the world the incredible socio-economic disruption that may result when dealing with a lethal pathogen that had not been previously recognized.  In other words, the curse of a very real biological hazard that is associated with tremendous uncertainty regarding transmission patterns, clinical features, lack of diagnostics, etc.  Needless to say, this was an issue of failure to recognize blatant signature patterns in publicly available Chinese media sources that were present for months prior to WHO awareness.  Such events are particularly dangerous for the world because of problems with signature recognition (emphasis on human recognition versus automated collection of the information) combined with inevitable bureaucratic hesitation to report.

 

However, that is precisely what happened again in the case of Jordan in April 2012, where in a manner similar to the emergence of SARS a blatant signature appeared in publicly available media.  This signature described an unknown respiratory agent that killed patients and staff in a Jordanian ICU, which was also associated with clear social disruption.  This signature was obliquely referenced by WHO and ECDC in their weekly reporting at the time as a non-prioritzed surveillance topic, and the amateur group Flu Trackers reported the thread to ProMED on April 22nd.  ProMED at the time declined to post the event.

 

As WHO has publicly indicated, the US Department of Defense was called in to assist in diagnostic evaluation but were unable to identify the pathogen.  The Jordanians elected not to formally report the event, perhaps because there was no apparent evidence of further spread in the community.  As a consequence, no medical responder in any of the countries connected by direct, non-stop air traffic was appears to have been notified.  We look back to the events in Hong Kong and Toronto, where patients and medical staff, unprepared and not pre-empted to prepare, were infected unknowingly by a previously undescribed pathogen that resulted in unnecessary loss of life and massive socio-economic disruption.  The key to any community’s sense of socio-economic stability in the context of such events is the integrity of their indigenous response capacity and capability- which effectively is “flying blind” with out warning.

 

It was only two days ago that the ECDC stated:

 

The limited information available about this outbreak does not allow for an assessment of whether human-to-human transmission has occurred or indeed whether the cases in this cluster had the same cause.

 

Here we note that WHO gave limited insights into what happened in Jordan seven months after the fact.  Here we note ECDC’s above assessment is provided also, more than seven months after the fact.  Here were the megalopolitan cities and countries placed on the line:

 

• Frankfurt, Germany
• Paris, France
• London, UK
• New York City, NY, USA
• Kuwait
• Budapest, Hungary
• Addis Ababa, Ethiopia
• Bucharest, Romania
• Kyiv, Ukraine
• Madrid, Spain
• Boston, MA, USA
• Tel Aviv, Israel

 

The connected events in KSA and Qatar involving novel coronavirus must also be addressed in this context, as lives were again put at risk.  It remains notable that had it not been for an Egyptian in the employ of the Saudis, ProMED would not have reported unusual respiratory disease that originated in KSA.  It may be then pointed out that Irene Lai of ISOS might not have been prompted to remind the international community of the curious events in Jordan.

 

 The combination of the above reveals a nested warning failure involving multiple source countries who hesitated to report and allow the International Health Regulations to do what they were supposed to do: provide warning. 

 

So, we have three countries over the span of seven months associated with a previously unknown lethal pathogen, possibly transmitting human to human, and associated with tremendous uncertainty regarding transmissibility, ecology, pathogenesis, etc.   Bottom line, there were no guarantees that translocation to other countries would not happen during all of this… hesitation… to warn.

 

Meanwhile, physicians, nurses, patients, and the humming economy of cities around the world were placed on the line while a gamble on translocation was placed.  As an emphasis of just how big this exposure footprint was, we offer the much more extensive list of countries connected by direct, non-stop air traffic to Jordan, Qatar, and KSA:

 

• Cairo, Egypt
• Dubai, UAE
• Karachi, Pakistan
• London, UK
• Beirut, Lebanon
• Paris, France
• Kuwait, Kuwait
• Islamabad, Pakistan
• Bahrain
• Frankfurt, Germany
• Mumbai, India
• New York, NY, USA
• Calicut, India
• Chicago, IL, USA
• Hong Kong, SAR
• Bangkok, Thailand
• Amsterdam, Netherlands
• Colombo, Sri Lanka
• Manila, Philippines
• Tel Aviv, Israel
• Peshawar, Pakistan
• Kuala Lumpar, Malaysia
• Abu Dhabi, UAE
• Cochin, India
• Alexandria, Egypt
• Riyadh, Saudi Arabia
• Zurich, Switzerland
• Trivandrum, India
• Damascus, Syria
• Hyderabad, India
• Lucknow, India
• Rome, Italy
• Madrid, Spain
• Cross-connectivity between Jordan, Qatar, and KSA
• And a multitude of other cities and countries

 

The Saudis pointed out the tremendous risk involved with issuance of a warning just prior to the Hajj.  But played out where warning was provided back in April during the events in Jordan, there would have been plenty of time for the Saudis to craft an appropriate message for Hajj pilgrims. This is the key.  Warnings (and forecasts, the work I am currently focused on at Ascel Bio) create opportunities – indeed new obligations to craft better pro-active guidance.  Armed with tornado, micro-burst, and hurricane warnings, we don’t fly airplanes into these hazards any more, we guide them along safer paths.  Informed of bad weather, we guide the population to wear raincoats, and take precautions.

 

What this experience shows, as now an ever-increasing list of experiences show, is that public health may not be the appropriate custodian of such functions and that there continues to be a role for non-government institutions and the private sector.  In America, private industry has stepped into such gaps historically, with success.  The example here is private meteorology.  Here in this case (and has been shown in other cases such as the 2009 H1N1 influenza pandemic), it is apparent this is a necessary step to protect our medical infrastructure and by proxy, our communities.  Private enterprise should at least be given the same opportunity and benefit of the doubt to protect communities that governments have been given, albeit with limited success, for the past 50 years. 

 

Let me be clear, there are forecasts available to the public today by my firm Ascel Bio.  We recently proved this with our forecasts regarding the now-recognized spike of cholera in Haiti and the early appearance of influenza in the US.  We have operated the National Infectious Disease Forecast Center here in the US for the last two years.  It functions independently of official public health mechanisms and supports a professional forecast and warning culture.  It is possible to do a better job recognizing high-threat indicators and communicating warnings to the public.  In the United States this very statement should be a serious wake-up call to any public health official wondering which way the wind is blowing, and what the right side of history is.

 

In the United States, government readers would be wise to examine precedent of NOAA’s partnership policy and pick up a copy of Michael Smith’s excellent book Warnings, with an eye towards the future.  Now is the time for these same readers to review case law relating to the use of weather forecasts and warnings, and reconsider what their obligations and liabilities really are.  There are many relevant precedents both in policy and in case law relating to the use of forecasts and warnings. 

 

Indeed, any US enterprise that claims “pandemic risk” or “influenza” as a “key risk” (for example in Section 1.A. of 10-K annual reports to shareholders) may wish to inform itself on the issues and precedents from meteorology – examining obligations established, for example, in the wake of the Delta Airlines Flight 191 crash.

 

 

 

 

3rd Novel Coronavirus in KSA: Progress in Warning

Kudos to Dr. Memish, Deputy Minister for Public Health of the KSA, for timely reporting of the 3rd novel coronavirus.  The messaging was concise and provided all of the necessary details to properly assess the situation from an international health perspective. 

We previously highlighted several problems with the human processes behind the warning sequence for the first case of novel coronavirus- problems that significantly inhibited realization of the 2005 IHRs' intent.  These delays in warning are often associated with previously unrecognized infectious agents, and unfortunately, also associated with IDIS Category 3-->5 level events on occasion.

Dr. Memish and the Ministry of Health faced an incredibly difficult decision, with billions on the line, in communicating about a pathogen that would be quickly associated in the public eye with SARS.  Here the Ministry has demonstrated a rapid course correction that is to be congratulated.

 

Review: The Novel Coronavirus Warning Sequence (KSA/UK)

A deliberate decision was made to wait for a period of time until the media reporting of this issue died down.  It is crucial to review processes and procedures in the alerting of potential international health crises.  In this particular instance, as with the previously discussed Jordan situation, the process remains... suboptimal.

First, a review of the publicly available reporting on the discovery of novel coronavirus in UK/KSA:

1. Sept 20, 2012 (Day 0).  Dr. Ali Mohamed  Zaki, an Egyptian national, reports finding a novel coronavirus at the Virology Laboratory of Dr Soliman Fakeeh Hospital Jeddah Saudi Arabia.  The non-profit organization Dr. Zaki reported to, ProMED, does not mention whether the International Health Regulations (IHRs) had been activated.  In ProMED contextual comment, there is no mention that coronaviridae, a large family of viruses, are found worldwide- including in the KSA.  There is no international pubic health threat assessment presented.
2. September 23rd (Day 3).  WHO announces they had been informed the prior day (Day 2), via the IHRs by the British, that they too had discovered a novel coronavirus.  WHO does not issue travel restrictions, however acknowledges they are in the midst of a threat assessment.  This report contributes to rapid media uptake of the information.
3. Oct 4th (Day 14).  The British report finding a novel coronavirus in a patient with unexplained severe acute respiratory illness, which was originally reported to the HPA on September 14th (Day -6).  The article was submitted on September 27th (Day +7).  An unknown length of time transpired in the drafting of this academic, presumably peer-reviewed article.  On the same day, CDC issues a Travel Notice.
4. October 21st (Day 31).  The media report that Saudi officials seek to fire Dr. Zaki for breaching official public health reporting protocols.
   
5. October 22nd (Day 32).  CDC posts a link in a non-prioritized position within the Clinician Outreach and Communication Activity (COCA) / Health Alert Network (HAN) to the original CDC MMWR report.  No recommendation for US physicians to actively surveil for a travel history and clinical findings is provided.  On the same day, KSA officials issue a statement rebuking the decisions made by Dr. Zaki and ProMED regarding how the information was handled.  Dr. Zaki was indeed fired.  Officials refer to the economic damage experienced by Toronto during SARS, and state,
   

We do trust ProMED-mail's editors and moderators will remember that our Ministry of Health bears ultimate responsibility for managing contagious disease within and even outside our boundaries. We take seriously our responsibilities to our citizens and our guests. This time of year, we assume an enormous responsibility to our Hajj pilgrims visiting Mecca, and then to the world community as our guests return home.

We note the title of the official who issued this statement includes "Director WHO Collaborating Center for Mass Gathering Medicine".  This then would imply one of two conditions:

1. Either Saudi officials truly were unaware of Dr. Zaki's findings before his note to ProMED, which happens far more often in these situations than not,
   
2. WHO did know the situation but made a decision not to publicly report, or
3. Saudi officials made the decision not to activate the IHRs based on their assessment, where the British clearly disagreed, albeit with the benefit of seeing the prior report out of KSA.
   

To be fair, it is a heavy political decision to issue warning of a "novel coronavirus" and invoke the fears of SARS right before the Hajj.  Billions of dollars are at stake, and no public official will feel comfortable taking a career risk over such action. 

The Saudi's comment is, ironically, a similar comment our team received during the emergence of H1N1 in Mexico, where Mexican officials were quoted as saying (paraphrased), "why didn't you tell us what was going on?"  Our response was, "but didn't you know already?" 

After 15 years of doing this work, we have found social media and human networks often tell us what is going on inside of a country, regardless of whether or not the officials truly know (or are willing to divulge).  This is also readily true inside the United States.  The truism is no one can know everything everytime everywhere.  And this certainly includes government officials.  As we have pointed out time and again (as have others) that nothing beats an astute observer proximal to an event.

On Oct 21st, one media report commented,

With SARS, it was the outbreak that came first. The virus was only discovered later.

“Now, it’s really the reverse situation...  We already have the virus and we’re waiting for an epidemic to show up or not show up.   It’s a much better scenario.”

We would agree with this point.  But the human process within the warning sequence arguably remains broken.

Assessing whether this particular warning sequence was a success or failure is dependent on several points in the timeline:

• The availability of an individual willing to breach official protocols to report infectious disease of international disruption potential.
• The coincidental receipt of two nearly identical virus samples from two different locations by the same diagnostic laboratory.
• The availability of diagnostic technology to rapidly identify the agent coupled to laboratory personnel with prior experience with the given family of viruses.

In other words, it was an extraordinary amount of luck that provided the world report of this novel coronavirus.  Conversely, it is utterly unknown how many times an unrecognized coronavirus killed someone either individually or in a cluster in the world in the last year, where the event went unreported for whatever reason.  We only know what is reported.  And we are now most certainly "at risk" of scaring ourselves more often since SARS due to an enhanced ability (thanks to newer diagnostic technology) to recognize pathogens that were probably always endemically there but unrecognized.  We are fortunate the novel coronavirus did not transmit efficiently during the Hajj.  Of course, we are fortunate to have the luxury of relaxed hindsight.

One would surmise that if the situation was solely in their hands (and not Dr. Zaki's), Saudi officials would not have activated the IHRs in a timely fashion due to concerns about response reprocussions during the Hajj.  In hindsight, the world can agree the outcome was a non-issue and no global response was required.  But this is said in hindsight, as similar "not a big deal" statements were made after SARS and the 2009 influenza pandemic.  Complacency yields surprise, which typically contributes to far more socio-economic disruption than most nations appreciate.

In being critical of the process, we propose the following:

• That the International Health Regulations still are not robust, despite official assurances to the contrary, and the position we take is the IHRs were activated outside of official channels thanks to public exposure through non-official channels.  The questions raised about the warning sequence during the emergence of H1N1 in Mexico, which caught the United States and Canada by surprise, remain valid today.  One will note these are precisely the same issues as raised during the emergence of SARS (see below, attached).  To go several steps further, there is little difference from the warning sequence observed during the 1957 or 1968 pandemics.  Interestingly, our experience exposing the UN as the source of the cholera disaster in Haiti also hightlights this tremendous capacity of officials to not be transparent, where UN officials continue to hesitate to admit fault despite evidence to the contrary.

• The linkage between global situational awareness for public health threats and local healthcare providers continues to be de-emphasized in the United States.  No state or local HAN was issued that discussed the situation in the UK or KSA despite the fact that our country is tremendously connected to these countries by international air traffic- even more so than China during the time of SARS.  This works against the promotion of that one astute clinician reporting a possible translocation of a poorly understood novel pathogen.  In the days of SARS, most US physicians first heard of the crisis through CNN or other news media outlets.  There is little difference today.  The implication is potential for rapid translocation, vis a vie the Toronto experience.  This leaves one with the impression that public health culture continues to be remarkably dis-integrated from daily clinical medicine, despite "lessons learned".  And no, most assuredly we do not have faith CDC/public health understood this particular pathogen well enough to make the call not to inform local clinicians.  The evidence resides in how the 1957, 1968 and 2009 influenza pandemics, SARS, HIV/AIDS, and the translocation of West Nile virus to the United States were handled during the initial recognition phase.
  

• There continues to be a fear of instigating "panic" via the issuance of official warnings.  This was true during the early days of Tornado forecasting, when commercial interests did not want the public to associate a given community with tornado activity.  The concern was a decrease in business activity.  Of course, failure to warn on a high Fujita Scale tornado would mean far more severe morbidity and mortality because the opportunity to be proactive in response would be lost.  How would tourists' impression of that community change if they knew the community deliberately witheld such information?  Once meteorological forecast and warning processes became imbedded in the fabric of our society, one could argue it created more social resilience, to include the viability of the economy.
  

It is the opinion of this team that the United States has taken at least ten year step backwards in biosurveillance R&D, operations, and global public health surveillance operations.  This is revealed in the complete duplication of effort reviewing the status of the DHS National Biosurveillance Integration Center through the National Laboratories.  And the International Health Regulations continue to be a suboptimal construct for rapid reporting of international health threats. 

Perhaps the axiom is true that it takes mass, geotemporally concentrated death that presents itself unexpectedly before a society decides to be outraged enough to force the installation of a proper forecast and warning capability for these kinds of threats.  In this, we perhaps find ourselves in the coil of Cassandra's Curse. 

In this, we find the creation of an international infectious disease forecast and warning center to be... essential.

 

Download Appendix 1 (Emergence of Severe Acute Respiratory Syndrome (SARS) in the People's Republic of China, 2002-2003: A Case Study to Define Requirements for Detection and Assessment of International Biological Threats)

The Biosurveillance Watch: What We Are Monitoring

We are often asked the important question of "what is the priority?" when monitoring an entire world of biological activity.  As of today, here is the answer to that question, keeping in mind we are based in the United States with a bias towards those biological agents that are potentially capable of acutely disrupting US-based infrastructure.  We use different prioritized reporting requirements for different clients / countries as appropriate.

1. A/H3N2 variant influenza virus within the US
2. A/H3N2 seasonal influenza virus within the US
3. A/H1N1 seasonal influenza virus within the US
4. (other type A influenza virus variants within the US)
5. RSV/adenovirus/metapneumovirus/influenza virus combinatory effect on medical infrastructure as winter approaches

Note there is no mention of A/H5N1 or other HPAI strains, novel coronvirus, Ebola virus, or other attention / headline-grabbing pathogens or marketing campaigns by research programs.  We always keep an eye on A/H5N1 reporting, for example, but until indicators of sustained human-human transmission have been reported it remains a low priority.  One must understand the associated indicator pattern if one does not have access to the direct medical or laboratory diagnostic data, of course.

Prioritized tracking bullets 6, 7, 8, 9, 10, etc include issues such as pertussis, however these have not proven to be acutely disruptive to the infrastructure at this juncture.

This is operational reality from our point of view, which is obviously not "hot and sexy".  It is always more interesting and exciting to talk about the most dramatically deadly pathogens such as novel coronavirus, Ebola, or H5N1.  But therein is the bias in human communication behavior: death > high morbidity > mild illness > largely asymptomatic illness.

One of the biggest responsibilities for a operationally-minded biosurveillance analysts is to focus on realistic probabilities and ask the question, "so what?"

 

 

 

Novel Coronavirus: Indication of Another Warning Failure?

On the one hand, the discovery at the single case level of a novel coronavirus among ICU patients in the UK and Saudi Arabia appears to be a success for international public health.  Our team was asked today what our global scanning systems portend, in terms of outcomes.  We have been busy reminding our clients that, with better diagnostic technology, we place ourselves at risk of the outcomes: in other words ignorance was once bliss.  Now, if you breathe the word coronavirus, most people call us in a fit of anxiety.  They forget that the coronavirus family contains routine pathogens that are forecastable inside the United States and elsewhere.  New technology provides us ever-greater insight now into what kills people around the world- this will not be the only "discovery" of course.  This will not be the only time we "discover" a pathogen that has probably been with us for millenia.

So while the Saudi Arabia / UK situation was a success, Irene Lai points out in ProMED that while the world focuses on this current event, they (the international media) apparently blew off what happened in Jordan last April and May.  What is clear is the ECDC picked up on media reporting out of Jordan, and both CDC and WHO were aware as early as April 26, 2012, of an unusual outbreak of respiratory disease in an intensive care unit that infected several staff members and killed one of them.  Let us say that the event signature pattern of what happened in Jordan should have suggested high placement on the list of any operational biosurveillance analyst at that time.

But the way the event was mentioned in the ECDC report at the time did not suggest any form of prioritization.  In other words, when one monitors the world for unusual or suspicious infectious disease events, how does one prioritize which event to expend effort attempting to verify or clarify?  What is perhaps disturbing is ProMED did not report this significant thread of reporting out of Jordan at the time.  HealthMap did not pick up on it either:

There was no publicly available alert or warning provided by ECDC, WHO, or CDC at the time. There is online evidence that the civilian amateur group known as Flu Trackers were following the thread as it was reported in the media.  However, there is no evidence they considered the thread important enough to prioritize as a message of notification to ProMED. 

One argument is the pathogen involved was not of public health consequence, or the rumor was disproved.  This was the benefit of having the now-defunkt WHO Outbreak Verification List (OVL).  The strength of the OVL was to express awareness and status of current / ongoing WHO investigations.  In the current regime of outbreak notification per the revised International Health Regulations, we have the appearance of ...silence... when it comes to these internal processes.  In other words, a lack of transparency. 

Amman, Jordan is connected, by direct non-stop airflight traffic to the following cities:

• Frankfurt, Germany
• Paris, France
• London, UK
• New York City, NY, USA
• Kuwait
• Budapest, Hungary
• Addis Ababa, Ethiopia
• Bucharest, Romania
• Kyiv, Ukraine
• Madrid, Spain
• Boston, MA, USA
• Tel Aviv, Israel

... and so on

 

The evidence suggests the information regarding this event thread was collected by several organizations, however there is no evidence of:

1. whether the Jordanians themselves properly notified WHO per the International Health Regulations versus the ECDC picking up on their media reports that then prompted query;
2. (despite partial recognition of an "important" event signature) prioritization by public health analysts for the issuance of warning;
3. no dissemination of information by public health authorities at all levels to the public regarding an event that may have met mandatory International Health Regulation reporting requirements; and
4. no official Health Advisory via the Health Alert Network (HAN) was issued to US physicians at the time... known in law enforcement parlance as a "Be On The Lookout (BOLO)".

In summary, the evidence therefore suggests that what happened in Jordan was recognized by some, but the significance of the signature pattern was not appreciated as a Priority Event.  There are a multitude of 'live' infectious disease events worldwide as this post is being typed.  The key is picking which ones warrant prioritization for closer scrutiny and communication to others. 

As a final re-emphasis, it appears the entire International Health Regulation process, from the international level to the local, failed to provide appropriate notice to physicians in those global cities who would have potentially been the recipients of translocating cases.  Namely, those physicians that reside within the United States.

 

 

West Nile Virus: Loss of a Warning Signature

During the emergence of West Nile virus in the United States from 1999-2006 (which year depended on what part of the country you are in) provided biosurveillance operators with a couple of easy indicators for impending transmission: wild bird die-offs (i.e. corvids) and equine illness / mortality. 

This year, however, in the current surge of West Nile transmission (our local example may be found here), we did NOT see pre-event bird die-offs reported.  In our part of the country there are plenty of corvids to monitor, but presumably thanks to herd immunity we were not provided the benefit of a month or two "heads up".  The fallback position was the early and abrupt WNV-positive mosquito pools noted 6 weeks in advance of the earliest known date of positivity. 

Although our part of the country hosts a substantial equine population, the West Nile vaccine has mitigated much of the illness we would have normally seen.  Indeed, this year it was almost as if human cases were sentinels for equine cases.

This year has indeed been associated with a warmer than usual winter, spring, and summer.  Temperature is a crucial driver for mosquito transmission competency, dramatically shortening the time it takes for a mosquito to go from a viremic avian blood meal to being able to infect another host (less than 24 hrs if incubated from 26-30 degrees Centrigrade in the lab, for instance).  However, as noted above, the loss of the expected signature pattern may present a challenge now for those US locales that have not yet seen a resurgence of West Nile- especially those cities who have deactivated or toned down their mosquito surveillance programs thanks to the poor economy.